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ROSEN’S
EMERGENCY MEDICINE
Concepts and Clinical Practice
9th Edition
Rosen’s
Emergency Medicine
Concepts and Clinical Practice
Editor-in-Chief
Ron M. Walls, MD
Executive Vice President and Chief Operating Officer, Brigham
Health; Neskey Family Professor of Emergency Medicine, Harvard
Medical School, Boston, Massachusetts
Senior Editors
Robert S. Hockberger, MD Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS
Emeritus Professor of Emergency Medicine, David Geffen School Medical Director, Los Angeles County EMS Agency; Professor
of Medicine at UCLA; Chair Emeritus, Department of Emergency of Clinical Medicine and Pediatrics, David Geffen School of
Medicine, Harbor-UCLA Medical Center, Los Angeles, California Medicine at UCLA; EMS Fellowship Director, Department of
Emergency Medicine, Harbor-UCLA Medical Center, Torrance,
California
Editors
Katherine Bakes, MD Amy H. Kaji, MD, PhD
Associate Professor, Department of Emergency Medicine, Associate Professor, Emergency Medicine, David Geffen School of
University of Colorado School of Medicine; Clinical Director Medicine at UCLA; Vice Chair of Academic Affairs, Department
of Community Affairs, Director, At-Risk Intervention and of Emergency Medicine, Harbor-UCLA, Los Angeles, California
Mentoring (AIM), Denver Health; Denver, Colorado
Michael VanRooyen, MD, MPH
Jill Marjorie Baren, MD, MBE, FACEP, FAAP Chairman, Emergency Medicine, Brigham and Women’s Hospital
Professor and Chair, Emergency Medicine, Perelman School of Professor, Department of Emergency Medicine, Harvard Medical
Medicine; Chief, Emergency Services, University of Pennsylvania School; Boston, Massachusetts; Director, Harvard Humanitarian
Health System, Philadelphia, Pennsylvania Initiative, Harvard University, Cambrige, Massachusetts
Timothy B. Erickson, MD, FACEP, FACMT, FAACT Richard D. Zane, MD, FAAEM
Chief, Division of Medical Toxicology, Department of Emergency The George B. Boedecker Professor and Chair, Department of
Medicine, Brigham and Women’s Hospital; Harvard Medical Emergency Medicine, University of Colorado School of Medicine;
School, Boston, Massachusetts; Faculty, Harvard Humanitarian Executive Director, Emergency Services, University of Colorado
Initiative, Cambridge, Massachusetts Health, Aurora, Colorado
Andy S. Jagoda, MD
Professor and Chair, Department of Emergency Medicine, Icahn
School of Medicine at Mount Sinai; Professor and Chair,
Emergency Medicine, Mount Sinai School of Medicine, New York,
New York
VOLUME 1
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
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and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
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contained in the material herein.
Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1992, 1988, and 1983.
Names: Walls, Ron M., editor. | Hockberger, Robert S., editor. | Gausche-Hill, Marianne,
editor.
Title: Rosen’s emergency medicine : concepts and clinical practice / [edited by] Ron M.
Walls, Robert S. Hockberger, Marianne Gausche-Hill.
Other titles: Emergency medicine
Description: Ninth edition. | Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2016055133 | ISBN 9780323354790 (hardcover : alk. paper) | ISBN
9789996111693 (v. 1: hardcover : alk. paper) | ISBN 9996111695 (v. 1: hardcover : alk.
paper) | ISBN 9789996111631 (v. 2 : hardcover : alk. paper) | ISBN 9996111636 (v. 2:
hardcover : alk. paper)
Subjects: | MESH: Emergencies | Emergency Medicine
Classification: LCC RC86.7 | NLM WB 105 | DDC 616.02/5—dc23
LC record available at https://lccn.loc.gov/2016055133
Printed in China
v
Contributors
Gallane Abraham, MD Aaron N. Barksdale, MD
Assistant Professor, Emergency Medicine, Icahn School of Assistant Professor, Emergency Medicine, University of
Medicine at Mount Sinai, New York, New York Nebraska Medical Center, Omaha, Nebraska
vii
viii Contributors
Timothy B. Erickson, MD, FACEP, FACMT, FAACT Jeffrey M. Goodloe, MD, NRP, FACEP
Chief, Division of Medical Toxicology, Department of Professor and EMS Section Chief, Director, Oklahoma Center
Emergency Medicine, Brigham and Women’s Hospital; for Prehospital and Disaster Medicine Department of
Harvard Medical School, Boston, Massachusetts; Faculty, Emergency Medicine, University of Oklahoma School of
Harvard Humanitarian Initiative, Cambridge, Massachusetts Community Medicine—Tulsa; Oklahoma Medical Director,
Medical Control Board EMS System for Metropolitan
Madonna Fernández-Frackelton, MD Oklahoma City and Tulsa, Tulsa, Oklahoma
Program Director, Emergency Medicine, Harbor-UCLA Medical
Center, Torrance, California; Professor of Medicine, David Eric Goralnick, MD, MS
Geffen School of Medicine, UCLA, Los Angeles, California Medical Director, Emergency Preparedness, Brigham and
Women’s Healthcare; Assistant Professor, Emergency
John T. Finnell, MD, MSc Medicine, Harvard Medical School; Instructor, Department
Associate Professor of Clinical Emergency Medicine, Indiana of Health Policy and Management, Harvard TH Chan School
University, Indianapolis, Indiana of Public Health, Boston, Massachusetts
N. Stuart Harris, MD, MFA, FRCP Edinburgh Robert S. Hoffman, MD, FAACT, FACMT, FRCP Edinburgh
Chief, Division of Wilderness Medicine, Fellowship Director, Professor, Emergency Medicine and Medicine, New York
MGH Wilderness Medicine Fellowship, Department of University School of Medicine; Attending Physician,
Emergency Medicine, Massachusetts General Hospital; Department of Emergency Medicine, Bellevue Hospital
Associate Professor, Emergency Medicine, Harvard Medical Center, New York, New York
School, Boston, Massachusetts
Christopher Hogrefe, MD
Danielle Hart, MD Assistant Professor, Departments of Medicine, Emergency
Associate Program Director and Director of Simulation, Medicine, and Orthopaedic Surgery, Northwestern University
Department of Emergency Medicine, Hennepin County Feinberg School of Medicine, Chicago, Illinois
Medical Center, Minneapolis, Minnesota
Jeffrey A. Holmes, MD
Benjamin W. Hatten, MD, MPH Attending Physician, Emergency Department, Maine Medical
Assistant Professor, Emergency Medicine, University of Center, Portland, Maine
Colorado–School of Medicine, Aurora, Colorado; Medical
Toxicologist, Rocky Mountain Poison and Drug Center, Jason A. Hoppe, DO
Denver Health Medical Center, Denver, Colorado Associate Professor, Emergency Medicine, University of
Colorado School of Medicine, Aurora, Colorado
Jag S. Heer, MD
Associate Professor of Clinical Medicine, David Geffen School Timothy Horeczko, MD, MSCR
of Medicine at University of California at Los Angeles, Los Department of Emergency Medicine, Harbor-UCLA Medical
Angeles, California; Attending Faculty Physician, Department Center, Torrance, California
of Emergency Medicine, Kern Medical Center, Bakersfield,
California Christopher Hoyte, MD
Fellowship Director, Associate Medical Director, Rocky
Carlton E. Heine, MD, PhD Mountain Poison and Drug Center; Director, Medical
Clinical Associate Professor, Elson S. Floyd College of Medicine, Toxicology Clinic, Section of Medical Toxicology,
Washington State University, Spokane Academic Center, Department of Emergency Medicine, University of Colorado
Spokane, Washington School of Medicine, Denver, Colorado
Robert L. Wears, MD, MS, PhD Ken Zafren, MD, FAAEM, FACEP, FAWM
Professor, Emergency Medicine, University of Florida, Emergency Programs Medical Director, State of Alaska,
Jacksonville, Florida; Visiting Professor, Clinical Safety Anchorage, Alaska; Clinical Professor, Department of
Research Unit, Imperial College London, London, England Emergency Medicine, Stanford University Medical Center,
Stanford, California; Staff Emergency Physician, Alaska
Lori Weichenthal, MD Native Medical Center, Anchorage, Alaska
Professor of Clinical Emergency Medicine, Emergency Medicine,
UCSF Fresno, Fresno, California Brian J. Zink, MD
Professor and Chair, Emergency Medicine, Alpert Medical
Katherine Welker, MD, MPH School of Brown University; Physician-in-Chief, Emergency
Attending Physician, Department of Emergency Medicine, San Medicine, Rhode Island, Newport and The Miriam Hospitals,
Diego, California; Toxicology Fellowship, Toxikon Providence, Rhode Island
Consortium, Cook County Hospital, Chicago, Illinois
Leslie S. Zun, MD, MBA
Matthew A. Wheatley, MD Professor and Chair, Emergency Medicine, Rosalind Franklin
Assistant Professor, Emergency Medicine, Emory University University of Medicine and Science-Chicago Medical School,
School of Medicine, Atlanta, Georgia North Chicago, Illinois; System Chair, Emergency Medicine,
Sinai Health System, Chicago, Illinois
John M. Wightman, MD, MA, FACEP
Director, Human Research Protection Program, 711th Human
Performance Wing, Air Force Research Laboratory, Wright-
Patterson Air Force Base, Ohio; Adjunct Professor,
Department of Military and Emergency Medicine, F. Edward
Hébert School of Medicine, Uniformed Services University,
Bethesda, Maryland; Clinical Professor, Department of
Emergency Medicine, Boonshoft School of Medicine, Wright
State University, Dayton, Ohio
Preface to the Ninth Edition
When we began planning for this ninth edition, we challenged make specific recommendations, and give the reader clear indica-
ourselves to make substantial and meaningful improvements to a tions of the preferred actions. This makes the book much more
book that has become the trusted standard in our field. With immediately relevant for emergency clinicians. We recognize that
broad and rapid changes occurring in health care and information emergency medicine is practiced by specialist emergency physi-
sciences, we recognized that relevance is not an accidental or cians, other physicians, residents and other trainees, and a variety
passive concept. To advance in relevance and consolidate the of nonphysician practitioners, so were careful to ensure that we
book’s position as the defining reference in our specialty, we care- are addressing all these groups with the same concise, highest
fully and deliberately undertook bold changes that we know make quality information and recommendations.
the book at once fresh, directive, and current in a way we have We revisited page counts for every chapter, adjusting alloca-
never before dared. tions where indicated, and added new chapters on several impor-
First, we created a substantially enhanced role for our editors, tant topics. We focused anew on consistency and redundancy,
one that would demand a great deal more of their time, creativity, enhancing the former and minimizing the latter. We moved
and energy. This helped us build a substantially different team some chapters to online access only, allowing us to add new topics
of editors, a perfectly balanced blend of those with great experi- of interest, such as drug therapy for older patients, and have
ence with prior editions and those who would bring new ideas provided a rich array of dynamic videos and images, especially in
and challenge our assumptions. Ron Walls was asked to serve as emergency ultrasound. We substantially expanded and reorganized
Editor-in-Chief, with Bob Hockberger in his long-standing role as the pediatric emergency medicine section, introducing dedicated
senior editor. Marianne Gausche-Hill, a highly respected academic pediatric chapters on airway management, procedural sedation,
emergency physician with service as editor on four previous and drug therapy. We introduced significant new material on
editions, stepped up to complete our senior editorial ranks. At emergencies in the pregnant woman, the patient with cancer, and
the editor level, Dr. Andy Jagoda returns and is joined by six a variety of other highly important clinical conditions. And, in
brilliant new editors drawn from academic programs from coast every possible case, we insisted on adherence to referencing and
to coast—Drs. Katherine Bakes, Jill Baren, Timothy Erickson, Amy writing requirements, a focus on relevant directive information,
Kaji, Michael VanRooyen, and Richard Zane. This dynamic and and appropriate use of prose and illustrations to provide the
innovative editorial team has dramatically redrawn our text’s perfect balance of depth, breadth, and ready accessibility.
blueprint by preserving what has served our readers the best, We are enormously proud of the result, a different, more read-
such as well-written discussions of the pathophysiologic basis of able “Rosen,” preserving the gravitas earned over 30 years as the
illness and injury, while moving in entirely new directions in most important book in our specialty while embracing the
providing pithy, clear, and succinct recommendations for diagno- modern era of emergency medicine practice and research and an
sis and treatment. entirely new generation of learners and practitioners. For those
We collectively determined that all references prior to 2010 who have owned prior editions, we appreciate your loyalty over
have been sufficiently long in the public domain that they no so many years and hope to reward it with a significantly improved
longer warrant citation. The infrequent exception to this is for and useful companion for your continuing learning and practice
guidelines that were issued in 2007 or later and have not been of this great specialty. For our newer readers, welcome, and thank
reissued or supplanted since. Strict adherence to our referenc- you for inspiring us to make significant changes to an iconic and
ing policy required authors to diligently provide well-researched timeless part of our academic heritage.
and detailed updates to their chapter content, based on only the
most recent and relevant medical literature. In cases in which Ron M. Walls
the literature is controversial or unclear, we have used the Robert S. Hockberger
combined experience and expertise of our authors and editors Marianne Gausche-Hill
to present cogent analyses of diagnostic and treatment options,
xxi
How This Medical Textbook Should Be Viewed by the Practicing Clinician
and Judicial System
The editors and authors of this text strongly believe that the complex practice of medicine, vagaries
of human diseases, unpredictability of pathologic conditions, and functions, dysfunctions, and
responses of the human body cannot be defined, explained, or rigidly categorized by any written
document. Therefore, it is neither the purpose nor intent of our textbook to serve as an authoritative
source on any medical condition, treatment plan, or clinical intervention, nor should our textbook be used
to rigorously define a standard of care that should be practiced by all clinicians.
Our written word provides the physician with a literature-referenced database and a reasonable
clinical guide combined with practical suggestions from individual experienced practitioners. We offer
a general reference source and clinical road map on a variety of conditions and procedures that may
confront emergency clinicians who are experienced in emergency medicine practice. This text cannot
replace physician judgment, cannot describe every possible aberration, nuance, clinical scenario,
or presentation, and cannot define rigid standards for clinical actions or procedures. Every medical
encounter must be individualized, and every patient must be approached on a case-by-case basis. No
complex medical interaction can possibly be reduced to the written word. The treatments, procedures,
and medical conditions described in this text do not constitute the total expertise or knowledge base
expected to be possessed by all emergency clinicians. Finally, many of the described complications and
adverse outcomes associated with implementing or withholding complex medical and surgical inter-
ventions may occur, even when every aspect of the intervention has been standard or performed
correctly.
Airway
Calvin A. Brown III | Ron M. Walls
[Prior to the engagement, the French fleet had met and was
convoying to port 180 vessels from America with food-stuffs of which
France was then in dire need. The British fleet encountered the
French 400 miles west of Ushant on May 28, and in the four days of
maneuvering and pursuit which followed, Howe displayed marked
energy and tactical skill. Though the French fleet was defeated in the
ensuing battle, it covered the escape of the convoy.—Editor.]
The French admiral on the evening of the 29th saw that he now
must fight, and at a disadvantage; consequently, he could not hope to
protect the convoy. As to save this was his prime object, the next best
thing was to entice the British out of its path. With this view he stood
away to the north-west; while a dense fog coming on both favored his
design and prevented further encounter during the two ensuing days,
throughout which Howe continued to pursue. In the evening of May
31 the weather cleared, and at daybreak the next morning the
enemies were in position, ready for battle, two long columns of ships,
heading west, the British twenty-five, the French again twenty-six
through the junction of the four vessels mentioned. Howe now had
cause to regret his absent six, and to ponder Nelson’s wise saying,
“Only numbers can annihilate.”
This time for maneuvering was past. Able tactician as he
personally was, and admirable as had been the direction of his efforts
in the two days’ fighting, Howe had been forced in them to realize
two things, namely, that his captains were, singly, superior in
seamanship, and their crews in gunnery, to the French; and again,
that in the ability to work together as a fleet the British were so
deficient as to promise very imperfect results, if he attempted any
but the simplest formation. To such, therefore, he resorted; falling
back upon the old, unskillful, sledge-hammer fashion of the British
navy. Arranging his ships in one long line, three miles from the
enemy, he made them all go down together, each to attack a specified
opponent, coming into action as nearly as might be at the same
instant. Thus the French, from the individual inferiority of the units
of their fleet, would be at all points over-powered. The issue justified
the forecast; but the manner of performance was curiously and
happily marked by Howe’s own peculiar phlegm. There was a long
summer day ahead for fighting, and no need for hurry. The order was
first accurately formed, and canvas reduced to proper proportions.
Then the crews went to breakfast. After breakfast, the ships all
headed for the hostile line, under short sail, the admiral keeping
them in hand during the approach as an infantry officer dresses his
company. Hence the shock from end to end was so nearly
simultaneous as to induce success unequalled in any engagement
conducted on the same primitive plan.
Picturesque as well as sublime, animating as well as solemn, on
that bright Sunday morning, was this prelude to the stern game of
war about to be played: the quiet summer sea stirred only by a breeze
sufficient to cap with white the little waves that ruffled its surface;
the dark hulls gently rippling the water aside in their slow advance, a
ridge of foam curling on either side of the furrow ploughed by them
in their onward way; their massive sides broken by two, or at times
three, rows of ports, whence, the tompions drawn, yawned the sullen
lines of guns, behind which, unseen, but easily realized by the
instructed eye, clustered the groups of ready seamen who served
each piece. Aloft swung leisurely to and fro the tall spars, which
ordinarily, in so light a wind, would be clad in canvas from deck to
truck, but whose naked trimness now proclaimed the deadly purpose
of that still approach. Upon the high poops, where floated the
standard of either nation, gathered round each chief the little knot of
officers through whom commands were issued and reports received,
the nerves along which thrilled the impulses of the great organism,
from its head, the admiral, through every member to the dark lowest
decks, nearly awash, where, as farthest from the captain’s own
oversight, the senior lieutenants controlled the action of the ships’
heaviest batteries.
On board the Queen Charlotte, Lord Howe, whose burden of sixty-
eight years had for four days found no rest save what he could snatch
in an arm-chair, now, at the prospect of battle, “displayed an
animation,” writes an eye-witness, “of which, at his age, and after
such fatigue of body and mind, I had not thought him capable. He
seemed to contemplate the result as one of unbounded satisfaction.”
By his side stood his fleet-captain, Curtis, of whose service among
the floating batteries, and during the siege of Gibraltar, the governor
of the fortress had said, “He is the man to whom the king is chiefly
indebted for its security;” and Codrington, then a lieutenant, who
afterwards commanded the allied fleets at Navarino. Five ships to the
left, Collingwood, in the Barfleur, was making to the admiral whose
flag she bore the remark that stirred Thackeray: “Our wives are now
about going to church, but we will ring about these Frenchmen’s ears
a peal which will drown their bells.” The French officers, both
admirals and captains, were mainly unknown men, alike then and
thereafter. The fierce flames of the Revolution had swept away the
men of the old school, mostly aristocrats, and time had not yet
brought forward the very few who during the Napoleonic period
showed marked capacity. The commander-in-chief, Villaret-Joyeuse,
had three years before been a lieutenant. He had a high record for
gallantry, but was without antecedents as a general officer. With him,
on the poop of the Montagne, which took her name from
Robespierre’s political supporters, stood that anomalous companion
of the generals and admirals of the day, the Revolutionary
commissioner, Jean Bon Saint-André, about to learn by experience
the practical working of the system he had advocated, to disregard all
tests of ability save patriotism and courage, depreciating practice and
skill as unnecessary to the valor of the true Frenchman.
As the British line drew near the French, Howe said to Curtis,
“Prepare the signal for close action.” “There is no such signal,”
replied Curtis. “No,” said the admiral, “but there is one for closer
action, and I only want that to be made in case of captains not doing
their duty.” Then closing a little signal book he always carried, he
continued to those around him, “Now, gentlemen, no more book, no
more signals. I look to you to do the duty of the Queen Charlotte in
engaging the flagship. I don’t want the ships to be bilge to bilge, but
if you can lock the yardarms, so much the better; the battle will be
the quicker decided.” His purpose was to go through the French line,
and fight the Montagne on the far side. Some doubted their
succeeding, but Howe overbore them. “That’s right, my lord!” cried
Bowen, the sailing-master, who looked to the ship’s steering. “The
Charlotte will make room for herself.” She pushed close under the
French ship’s stern, grazing her ensign, and raking her from stern to
stem with a withering fire, beneath which fell three hundred men. A
length or two beyond lay the French Jacobin. Howe ordered the
Charlotte to luff, and place herself between the two. “If we do,” said
Bowen, “we shall be on board one of them.” “What is that to you,
sir?” asked Howe quickly. “Oh!” muttered the master, not inaudibly.
“D—n my eyes if I care, if you don’t. I’ll go near enough to singe some
of our whiskers.” And then, seeing by the Jacobin’s rudder that she
was going off, he brought the Charlotte sharp round, her jib boom
grazing the second Frenchman as her side had grazed the flag of the
first.
From this moment the battle raged furiously from end to end of
the field for nearly an hour,—a wild scene of smoke and confusion,
under cover of which many a fierce ship duel was fought, while here
and there men wandered, lost, in a maze of bewilderment that
neutralized their better judgment. An English naval captain tells a
service tradition of one who was so busy watching the compass, to
keep his position in the ranks, that he lost sight of his antagonist, and
never again found him. Many a quaint incident passed, recorded or
unrecorded, under that sulphurous canopy. A British ship, wholly
dismasted, lay between two enemies, her captain desperately
wounded. A murmur of surrender was somewhere heard; but as the
first lieutenant checked it with firm authority, a cock flew upon the
stump of a mast and crowed lustily. The exultant note found quick
response in hearts not given to despair, and a burst of merriment,
accompanied with three cheers, replied to the bird’s triumphant
scream. On board the Brunswick, in her struggle with the Vengeur,
one of the longest and fiercest fights the sea has ever seen, the cocked
hat was shot off the effigy of the Duke of Brunswick, which she bore
as a figure-head. A deputation from the crew gravely requested the
captain to allow the use of his spare chapeau, which was securely
nailed on, and protected his grace’s wig during the rest of the action.
After this battle with the ships of the new republic, the partisans of
monarchy noted with satisfaction that, among the many royal figures
that surmounted the stems of the British fleet, not one lost his
crown. Of a harum-scarum Irish captain are told two droll stories.
After being hotly engaged for some time with a French ship, the fire
of the latter slackened, and then ceased. He called to know if she had
surrendered. The reply was, “No.” “Then,” shouted he, “d—n you,
why don’t you fire?” Having disposed of his special antagonist
without losing his own spars, the same man kept along in search of
new adventures, until he came to a British ship totally dismasted and
otherwise badly damaged. She was commanded by a captain of
rigidly devout piety. “Well, Jemmy,” hailed the Irishman, “you are
pretty well mauled; but never mind, Jemmy, whom the Lord loveth
he chasteneth.”
The French have transmitted to us less of anecdote, nor is it easy
to connect the thought of humor with those grimly earnest
republicans and the days of the Terror. There is, indeed, something
unintentionally funny in the remark of the commander of one of the
captured ships to his captors. They had, it was true, dismasted half
the French fleet, and had taken over a fourth; yet he assured them it
could not be considered a victory, “but merely a butchery, in which
the British had shown neither science nor tactics.” The one story,
noble and enduring, that will ever be associated with the French on
the 1st of June is in full keeping with the temper of the times and the
enthusiasm of the nation. The seventy-four-gun ship Vengeur, after a
three hours’ fight, yardarm to yardarm, with the British Brunswick,
was left in a sinking state by her antagonist, who was herself in no
condition to help. In the confusion, the Vengeur’s peril was for some
time not observed; and when it was, the British ships that came to
her aid had time only to remove part of her survivors. In their report
of the event the latter said: “Scarcely had the boats pulled clear of the
sides, when the most frightful spectacle was offered to our gaze.
Those of our comrades who remained on board the Vengeur du
Peuple, with hands raised to heaven, implored, with lamentable
cries, the help for which they could no longer hope. Soon
disappeared the ship and the unhappy victims it contained. In the
midst of the horror with which this scene inspired us all, we could
not avoid a feeling of admiration mingled with our grief. As we drew
away, we heard some of our comrades still offering prayers for the
welfare of their country. The last cries of these unfortunates were,
‘Vive la République!’ They died uttering them.” Over a hundred
Frenchmen thus went down.
Seven French ships were captured, including the sunk Vengeur.
Five more were wholly dismasted, but escaped,—a good fortune
mainly to be attributed to Howe’s utter physical prostration, due to
his advanced years and the continuous strain of the past five days.
He now went to bed, completely worn out. “We all got round him,”
wrote an officer, Lieutenant Codrington, who was present; “indeed, I
saved him from a tumble, he was so weak that from a roll of the ship
he was nearly falling into the waist. ‘Why, you hold me up as if I were
a child,’ he said good-humoredly.” Had he been younger, there can
be little doubt that the fruits of victory would have been gathered
with an ardor which his assistant, Curtis, failed to show.
23. Nelson’s Strategy at Copenhagen[67]
MEMORANDUM
(Secret)
Victory, off Cadiz, 9th October, 1805.